Psychiatrists, psychiatric NPs and psychiatric PAs provide medication management using E/M codes and psychotherapy services. There are specific rules for performing both on a calendar day. Be sure to review the behavioral health coding guide for more specific information.
When a CPT® code is defined by time, the clinician must document time in the medical record.
Examples of this are:
- some psychiatry codes
- certain physical therapy modalities
- critical care services
- the second level discharge visit
- prolonged services
When you look at the definition of a CPT® code, if time is listed, document time in the medical record.
You can also use time to select Evaluation and Management codes if typical time is listed for that code in the CPT® book and the visit is predominately counseling and coordination of care. Document the total time of the visit, the fact that more than 50% of the visit was counseling and the nature of the counseling.
Which CPT® codes have a time component?
- certain E/M codes when the visit is predominately counseling/coordination of care, (99201–99215, 99221–99233, 99241–99255, 99341–99350)
- second level discharge visit, (99239)
- critical care, (99291-99292)
- initial observation care, (99218-99220)
- subsequent observation care, (99224-99226)
- observation or inpatient hospital care (99234-99236)
- some behavioral health, psychiatry, physical therapy nutrition and diabetic education codes,
- prolonged services
If the code descriptor has time indicated, it is a time-based code.
NOTE: Medicare requires start and stop times for prolonged services
Documentation requirements | Using time to select the code
- For psychiatry, write the total time of the visit in the note
- For physical therapy, use a form that indicates parameters of the visit, including time
- In critical care, document the time in the hospital note for each visit in a calendar date. Add together the total time spent in a calendar date.
- Document time in the medical record, not just on the billing record
- For Psychiatry and PT, the billing clinician must reach half of the stated time to bill the service. If one unit is 15 minutes, bill for it if 8 minutes are done. This is not allowed for selecting an E/M service.
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